Dictation of Outside Imaging studies. Part1: For EMS and Trauma Service Patients in the ED

Transcription

1 Memorandum Number: RM Category: Operating Procedures SUBJECT: Dictation of Outside Imaging studies Part1: For EMS and Trauma patients in the ED Part2: General policy for studies other than EMS and Trauma patients in the ED Part1: For EMS and Trauma Service Patients in the ED PURPOSE Part 1: To establish the responsibility and methods for securing dictation of studies and continuum of care of EMS and Trauma patients who arrive at Shands with outside images and are being treated acutely in the ED. To act in accordance with ALARA standards in reducing patient dose by avoiding the duplication of imaging exams involving radiation when possible and reduce time to diagnosis of critical injury when possible from that outside imaging data. POLICY Part 1: The workflow applicable to this policy is on an appended flow chart for clear and ready reference and also appears on the Radiology public web site under the section titled Patient Care Physicians who request an official dictation of outside images must do so in one of the following manners: 1) A disk is provided containing images that is, preferably, compatible with and can be loaded into the Shands image storage and transfer systems. 2) Alternatively the studies may be available on our PACS and/or Stentor viewing systems by way of direct image transfer protocols that have been previously arranged with some referring entities. 3) A study may also be read if it can be opened with a reader on the disc but not transferred to our PACS/Stentor system. An order for outside read must be placed in the Shands system to provide the radiologist with a valid accession number for dictation. If the Radiologist determines that the outside images are not of diagnostic quality, an outside reading about the content of the exam will not be performed and that determination will be

2 SPECIAL INSTRUCTIONS Part 1: documented in an official report. The workflow applicable to this policy is on an appended flow chart for clear and ready reference and will appear on the Radiology public web site under the section titled Patient Care. 1. The EMS or Trauma service is responsible for transporting a disk containing outside images to the South campus reading room. a. The clerical assistant or a back up provided from technologist staff will load the disk into Stentor when available. It must first be determined that the disk will open on a Shands computer or no dictation of findings can be performed. b. The disk may be compatible with the Shands image storage and transfer systems (PACS and/or Stentor) in which case it will be loaded into the system and interpreted using optimal viewing tools. Alternatively if a direct transfer protocol has been successful the study can be read in the same manner. c. If a disc can be opened but not uploaded to our PACS/Stentor system it will be read by opening the study and evaluating it with the reading tools provided on the disc. 2. Once the status of the disc loading on a Shands computer has been determined the order placed in the Shands system to generate a valid accession number will report whether the disc could be loaded, what source it has been read from and, if it is sufficient for medical decision making and, if sufficient, a full radiology report will be dictated in the usual manner. a. Downtime procedures will apply as necessary.

3 Part 2: General Policy for Studies Other than EMS and Trauma Service Patients in the ED PURPOSE Part 2: POLICY Part 2: To establish the responsibility and methods for optional dictation of studies on patients who arrive at Shands with outside images other than those who are being treated acutely in the ED. To act in accordance with ALARA standards in reducing patient dose by avoiding the duplication of imaging exams involving radiation when possible and reduce time to diagnosis when possible from that imaging data. Physicians who request an official dictation of outside images must do so in one of the following manners: 1) A disk is provided containing images that is, preferably, compatible with and can be loaded into the Shands image storage and transfer systems. 2) Alternatively the studies may be available on our PACS and/or Stentor viewing systems by way of direct image transfer protocols that have been previously arranged with some referring entities. 3) A study may also be read if it can be opened with a reader on the disc but not transferred to our PACS/Stentor system. If the individual Radiologist asked to provide this service agrees that individual Radiologist will determine whether an official report will be generated. Moreover, that individual Radiologist will set the terms of the viewing and consultation of those images whether that is verbally in person, via a messenger delegated by the provider asking for the consultation, or by phone to similar or the same type of individuals just named. An order for outside read may be placed in the Shands system to provide the radiologist with a valid accession number for dictation. Whether such a formal reading and report is done is solely at the discretion of the individual Radiologist asked to provide such a consultation may only be done with the prior agreement of that proposed interpreting Radiologist. Individual radiologist may engage in any other reasonable interaction to modify or arrive at a mutually agreeable and suitable means to view and report on such studies with individual providers.

4 SPECIAL INSTRUCTIONS Part 2: 1. If an formal, dictated report is agreed to by the individual Radiologist asked to provide the consultation, the referring provider is responsible for transporting a disk containing outside images to film library 2. At the film library a. It must be determined whether the disk will open on a Shands computer or no dictation can be performed. b. The disk may be compatible with the Shands image storage and transfer systems (PACS and/or Stentor) in which case it will be loaded into the system and read with optimal viewing tools. Alternatively, if a direct transfer protocol has been successful the study can be read in the same manner. c. If a disc can be opened but not uploaded to our PACS/Stentor system it will be read by opening the study and evaluating it on a computer local to the area where the interpreting Radiologist chooses to view the study with the reading tools provided on the disc. 3. Once the status of the disc loading on a Shands computer has been determined the order placed in the Shands system to generate a valid accession number will be used to generate a report stating if the images are sufficient for medical decision making and, if sufficient, a full, routine report about the findings will be dictated in the usual manner. a. Downtime procedures will apply as necessary. APPROVED: Reviewed/Revised: Date: 1/11 Anthony Mancuso, M.D. Chairman, Department of Radiology Date: 1/11 Melinda Chitty Administrative Director, Department of Radiology

5 RM 02-34(2)